Provider Demographics
NPI:1932216629
Name:MINNEMAN-FOWLER, SUE ANN (DDS)
Entity Type:Individual
Prefix:DR
First Name:SUE
Middle Name:ANN
Last Name:MINNEMAN-FOWLER
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 418
Mailing Address - Street 2:
Mailing Address - City:MAYSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28555-0418
Mailing Address - Country:US
Mailing Address - Phone:910-743-2521
Mailing Address - Fax:910-743-2531
Practice Address - Street 1:1002 JENKINS AVENUE
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28555
Practice Address - Country:US
Practice Address - Phone:910-743-2521
Practice Address - Fax:910-743-2531
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC054101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8995986Medicaid
NC8995986Medicaid